Has the Big MAC Bitten Off More Than It Can Chew? October 4, 2009
MACs (Medicare Administrative Contractors) are the new and supposedly improved version of what we have known as Medicare Carriers for years. But who are they and how did they get here? Like their Carrier predecessors, they are private insurance companies that bid on the jurisdictional contracts with CMS. The theory in creating these multi-state jurisdictions was that one company could manage a four-state region more economically than four different companies could manage the individual states. With that in mind, the insurance companies that bid on these MAC jurisdictions closed offices, consolidated staff and made other changes necessary to cut costs and get competitive for the bidding process. Of course, as with many government contracts, the lowest bidder wins. This all sounds good until you begin to see that some of the corners that were cut in the name of being more "economical" may be hurting the providers. For example, at the request of several members of one state's ambulance association, I sat in on an "information session" provided by a new MAC. During that session it became clear that this company intended to (and in fact did) deny claims based solely on the destination modifier. In my opinion, to deny a trip to what CMS says is a covered destination solely because of the destination modifier is absolutely inappropriate. Specifically, the MAC was denying any claim that had an R as the destination, basically saying if you are healthy enough to go to home ("R" is for residence), you don't need an ambulance. They admitted to me they were not even looking at the narrative to see the patient's condition. When I asked why, their response was that they did not have the ability to kick out these personal claims, so they were just denying them and forcing the ambulance company to appeal. Sounds like some of these MACs bid too little to effectively manage the contract. And who suffers? We do.
G. Christopher Kelly is an attorney who focuses on federal laws and regulations as they relate to the healthcare industry and specifically to the ambulance industry. Chris lectures and advises EMS clients across the U.S. This article is not intended to be construed as legal advice. For more information or questions, reach Chris at firstname.lastname@example.org or by contacting EMS Consultants, Ltd., 800/342-5460.